Journal of General Internal Medicine

, Volume 23, Issue 2, pp 169–174 | Cite as

Community-based Preferences for Stool Cards versus Colonoscopy in Colorectal Cancer Screening

  • Ann C. DeBourcy
  • Scott Lichtenberger
  • Susanne Felton
  • Kiel T. Butterfield
  • Dennis J. Ahnen
  • Thomas D. DenbergEmail author
Original Article



In the United States, compliance with colorectal cancer (CRC) screening recommendations remains suboptimal. Professional organizations advocate use of shared decision making in screening test discussions, but strategies to facilitate informed choice in CRC screening have not been well elucidated.


The objectives of the study were to determine screening test preference among colonoscopy-naïve adults after considering a detailed, written presentation of fecal occult blood testing (FOBT) and colonoscopy and to assess whether their preferences are associated with demographic characteristics, attitudes, and knowledge.


The design of the study was a cross-sectional survey.


Colonoscopy-naïve supermarket shoppers age 40–79 in low- and middle-income, multiethnic neighborhoods in Denver, CO, reviewed a detailed, side-by-side description of FOBT and colonoscopy and answered questions about test preference, strength of preference, influence of physician recommendation, basic knowledge of CRC, and demographic characteristics.

Measurements and Main Results

Descriptive statistics characterized the sample, and bivariate and multivariable logistic regression analyses identified correlates of screening test preference. In a diverse sample of 323 colonoscopy-naïve adults, 53% preferred FOBT, and 47% preferred colonoscopy for CRC screening. Individuals of Latino ethnicity and those with lower educational attainment were more likely to prefer FOBT than non-Latino whites and those with at least some college. Almost half of the respondents felt “very strongly” about their preferences, and one third said they would adhere to their choice regardless of physician recommendation.


After considering a detailed, side-by-side comparison of the FOBT and colonoscopy, a large proportion of community-dwelling, colonoscopy-naïve adults prefer FOBT over colonoscopy for CRC screening. In light of professional guidelines and time-limited primary care visits, it is important to develop improved ways of facilitating informed patient decision making for CRC screening.


colorectal cancer screening colonoscopy fecal occult blood testing patient preferences informed decision-making 



This study was supported in part by an American Cancer Research Scholar Grant in Cancer Control: Psychosocial and Behavioral Research MRSG-06-081-01-CPPB (Denberg, PI). Connolly Butterfield provided assistance with survey collection.

Conflict of Interest

None disclosed.


  1. 1.
    Jemal A, Siegel , Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43–66.PubMedCrossRefGoogle Scholar
  2. 2.
    Walsh JM, Terdiman JP. Colorectal cancer screening: scientific review. Jama. 2003;289:1288–96.PubMedCrossRefGoogle Scholar
  3. 3.
    U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137:129–31.Google Scholar
  4. 4.
    Rex DK, Johnson DA, Lieberman DA, Burt RW, Sonnenberg A. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. American College of Gastroenterology. Am J Gastroenterol. 2000;95:868–77.PubMedGoogle Scholar
  5. 5.
    Davila RE, Rajan E, Baron TH, Adler DG, Egan JV, Faigel DO, Gan SI, Hirota WK, Leighton JA, Lichtenstein D, Qureshi WA, Shen B, Zuckerman MJ, VanGuilder T, Fanelli RD. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546–57.PubMedCrossRefGoogle Scholar
  6. 6.
    Winawer S, Fletcher , Rex D, Bond J, Burt , Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544–60.PubMedCrossRefGoogle Scholar
  7. 7.
    Flach SD, McCoy KD, Vaughn TE, Ward MM, Bootsmiller BJ, Doebbeling BN. Does patient-centered care improve provision of preventive services? J Gen Intern Med. 2004;19:1019–26.PubMedCrossRefGoogle Scholar
  8. 8.
    Brody DS. The patient’s role in clinical decision-making. Ann Intern Med. 1980;93:718–22.PubMedGoogle Scholar
  9. 9.
    Rex DK. Colonoscopy: the dominant and preferred colorectal cancer screening strategy in the United States. Mayo Clin Proc. 2007;82:662–4.PubMedGoogle Scholar
  10. 10.
    Harewood GC, Lieberman DA. Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening. Clin Gastroenterol Hepatol. 2004;2:72–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Phillips KA, Liang SY, Ladabaum U, Haas J, Kerlikowske K, Lieberman D, Hiatt, Nagamine M, Van Bebber SL. Trends in colonoscopy for colorectal cancer screening. Med Care. 2007;45:160–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Centers for Disease Control. Behavioral Risk Factor Surveillance System. Prevalence data: adults aged 50 who have had a blood stool test within the past two years; 2006. Available at: = 2002&yr = 2006&cat = CC&state = US&bkey = 20060032&qkey = 4424&qtype = C&grp = 0&SUBMIT2 = Compare (accessed August 8, 2007).
  13. 13.
    Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin. 2006;56:11–25. quiz 49–50.PubMedGoogle Scholar
  14. 14.
    Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.PubMedGoogle Scholar
  15. 15.
    Wackerbarth SB, Tarasenko YN, Joyce JM, Haist SA. Physician colorectal cancer screening recommendations: an examination based on informed decision making. Patient Educ Couns. 2007;66:43–50.PubMedCrossRefGoogle Scholar
  16. 16.
    Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin. 2007;57:90–104.PubMedGoogle Scholar
  17. 17.
    Leard LE, Savides TJ, Ganiats TG. Patient preferences for colorectal cancer screening. J Fam Pract. 1997;45:211–8.PubMedGoogle Scholar
  18. 18.
    Ling BS, Moskowitz MA, Wachs D, Pearson B, Schroy PC. Attitudes toward colorectal cancer screening tests. J Gen Intern Med. 2001;16:822–30.PubMedCrossRefGoogle Scholar
  19. 19.
    Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med. 1999;14:432–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Janz NK, Lakhani I, Vijan S, Hawley ST, Chung LK, Katz SJ. Determinants of colorectal cancer screening use, attempts, and non-use. Prev Med. 2007;44:452–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Wolf RL, Basch CE, Brouse CH, Shmukler C, Shea S. Patient preferences and adherence to colorectal cancer screening in an urban population. Am J Public Health. 2006;96:809–11.PubMedCrossRefGoogle Scholar
  22. 22.
    American Statistics Association. In: Proceedings of the Section on Survey Research Methods. Alexandria, VA; 1995:1075–1080.Google Scholar
  23. 23.
    Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13:522–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Han PK, Coates RJ, Uhler RJ, Breen N. Decision making in prostate-specific antigen screening National Health Interview Survey, 2000. Am J Prev Med. 2006;30:394–404.PubMedCrossRefGoogle Scholar
  25. 25.
    Morbidity and Mortality Weekly Report. Screening for colorectal cancer—United States, 1997. Morb Mortal Wkly Rep. 1999;48:116–21.Google Scholar
  26. 26.
    Sheikh RA, Kapre S, Calof OM, Ward C, Raina A. Screening preferences for colorectal cancer: a patient demographic study. South Med J. 2004;97:224–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Walsh JM, Kaplan CP, Nguyen B, Gildengorin G, McPhee SJ, Perez-Stable EJ. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004;19:156–66.PubMedCrossRefGoogle Scholar
  28. 28.
    Denberg TD, Melhado TV, Coombes JM, Beaty BL, Berman K, Byers TE, Marcus AC, Steiner JF, Ahnen DJ. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med. 2005;20:989–95.PubMedCrossRefGoogle Scholar
  29. 29.
    Guerra CE, Dominguez F, Shea JA. Literacy and knowledge, attitudes, and behavior about colorectal cancer screening. J Health Commun. 2005;10:651–63.PubMedCrossRefGoogle Scholar
  30. 30.
    Klabunde CN, Lanier D, Breslau ES, Zapka JG, Fletcher RH, Ransohoff DF, Winawer SJ. Improving colorectal cancer screening in primary care practice: innovative strategies and future directions. J Gen Intern Med. 2007;22:1195–205.PubMedCrossRefGoogle Scholar
  31. 31.
    The Multicentre Australian Colorectal-neoplasia Screening (MACS) Group. A comparison of colorectal neoplasia screening tests: a multicentre community-based study of the impact of consumer choice. Med J Aust. 2006;184:546–50.Google Scholar
  32. 32.
    Segnan N, Senore C, Andreoni B, Arrigoni A, Bisanti L, Cardelli A, Castiglione G, Crosta C, DiPlacido , Ferrari A, Ferraris , Ferrero F, Fracchia M, Gasperoni S, Malfitana G, Recchia S, Risio M, Rizzetto M, Saracco G, Spandre M, Turco D, Turco P, Zappa M. Randomized trial of different screening strategies for colorectal cancer: patient response and detection rates. J Natl Cancer Inst. 2005;97:347–57.PubMedCrossRefGoogle Scholar
  33. 33.
    Lafata JE, Divine G, Moon C, Williams LK. Patient-physician colorectal cancer screening discussions and screening use. Am J Prev Med. 2006;31:202–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Brawarsky P, Brooks D, Mucci LA, Wood PA. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect Prev. 2004;28:260–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Ahlquist DA. Occult blood screening. Obstacles to effectiveness. Cancer. 1992;70:1259–65.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Ann C. DeBourcy
    • 1
  • Scott Lichtenberger
    • 1
  • Susanne Felton
    • 1
  • Kiel T. Butterfield
    • 1
  • Dennis J. Ahnen
    • 1
  • Thomas D. Denberg
    • 1
    Email author
  1. 1.Department of MedicineUniversity of Colorado at Denver School of MedicineAuroraUSA

Personalised recommendations